For some time now we've been told that health information technology (HIT) is the wave of the future and that, eventually, paper prescriptions will be a thing of the past, and all of our medical records stored electronically.

A key question is the time-line defining "eventually." Various studies have revealed that doctors have been slow to switch to electronic health records (EHRs). And according to a new study, hospitals are also slow to adopt EHRs maybe even slower than the doctors.

The study, published in the New England Journal of Medicine (NEJM), was led by researchers at Harvard University (Cambridge), including David Blumenthal, MD, chosen by President Barack Obama to be national coordinator of HIT.

The study concludes that the "very low levels" of adoption of EHRs in U.S. hospitals suggest that policymakers face "substantial obstacles" to achieve healthcare performance goals that depend on HIT.

The study suggests that a policy strategy focused on financial support, interoperability, and training of technical support staff may be necessary to spur adoption of EHRs in U.S. hospitals.

The researchers surveyed all acute care hospitals (about 3,000) that are members of the American Hospital Association (Chicago), and it found that, based on responses from 63.1% of hospitals surveyed, only 1.5% of U.S. hospitals have a comprehensive EHR system (meaning, present in all clinical units), and an additional 7.6% have a basic system (present in at last one clinical unit). Computerized provider-only entry for medications has been implemented in only 17% of hospitals, according to the study.

The authors also note finding that larger hospitals, those located in urban areas, and teaching hospitals are more likely to have EHRs.

Respondents cited capital requirements and high maintenance costs as the primary barriers to implementation, although hospitals with EHRs were less likely to cite these barriers than hospitals without such systems.

President Obama has pledged to spend roughly $50 billion over five years to promote the adoption and use of HIT, and the American Recovery and Reinvestment Act of 2009 will provide $19 billion over the next two years for that cause.

Hoping to leverage some of that money, a new public/private partnership called PaperFree Tampa Bay launched last month. This program plans to deploy more than 100 electronic healthcare "ambassadors" with the goal to convert 100% of physicians in the Tampa Bay area from paper prescriptions to electronic prescribing.

According to project organizers, the effort is a first step toward implementation of connected EHRs to improve patient safety and reduce costs. The goal of PaperFree Tampa Bay is to serve as a prototype for other communities across the U.S. (Medical Device Daily, March 24, 2009).

While American doctors have been slow to computerize their operations, a recent New York Times editorial points out that a vast majority of doctors in four other industrialized nations have adopted EHRs. But even in those countries hospitals are thought to be lagging, the editorial notes.

"The main impediment is money. Many hospitals simply do not have the capital to buy systems that can cost $20 million to $200 million, especially when so many are struggling to remain solvent," the Times editorial says. "Hospitals also worry about high maintenance costs, an uncertain payoff on their investment, a lack of staff with adequate technical expertise and resistance from doctors."

In a perspective article accompanying the study in NEJM, Blumenthal writes that the HIT components in the stimulus package collectively labeled HITECH in the law reflect a "shared conviction among the fledging Obama administration, the Congress, and many healthcare experts that electronic information systems are essential to improving the health and healthcare of Americans."

However, Blumenthal also cites several barriers to the adoption and use of EHRs: their substantial cost, the perceived lack of financial return from investing in them, the technical and logistic challenges involved in installing, maintaining, and updating them, and consumers' and physicians' concerns about privacy and security of electronic health information.

From the standpoint of physicians, he writes, the HITECH legislation's most important provision may be $17 billion in financial incentives intended to get doctors and hospitals to adopt and use EHRs. Starting in 2011, doctors can receive extra Medicare payments for the "meaningful use" of a certified EHR that can exchange data with other parts of the healthcare system. Blumenthal says these payments can total as much as $18,000 in the first year in the case of doctors who adopt in 2011 or 2012, with at least $15,000 for those who adopt in 2013 and a "slightly lower amount" for those who do so in 2014.

Because these financial incentives are gradually reduced and then ended in 2016, Blumenthal says doctors who demonstrate meaningful use starting in 2011 could collect $44,000 over five years. Waiting until 2013 would result in a maximum bonus of $27,000 over three years, he said.

According to Blumenthal, experts estimate the cost of buying, installing and implementing an EHR in a medical office at about $40,000.

On the flip side of the incentives, the law also threatens to impose financial penalties for those who do not adopt these systems. Doctors not using EHRs by 2015 will lose 1% of their Medicare fees, 2% in 2016, and 3% in 2017. Hospitals also face penalties, according to Blumenthal, including cuts in their annual updates under the DRG system.

"Spurring the adoption of EHRs and other HIT will probably require more than financial carrots and sticks," Blumenthal writes, and that many doctors and hospitals will need technical help to keep their systems working and to update them as technology improves.

"The nation's economic woes have given birth to an unprecedented federal effort to modernize the information systems of a troubled healthcare system," Blumethal says. "It is now up to the government and the nation's healthcare professionals and facilities to turn this opportunity into real improvements in the health and healthcare of Americans."

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